Radial Artery Spasm, Excision of Avulsed Fragment and Uncompromised Flow: An Oxymoron in Invasive Cardiology

J INVASIVE CARDIOL 2023;35(4):E217-E218.

Key words: avulsion, coronary angiography, radial artery, spasm, vasodilation

A 63-year-old man with a history of smoking, panic attacks, and positive treadmill test was referred for invasive coronary angiography (CA). By a right radial artery (RA) approach, there was difficulty advancing the sheath and the standard guidewire. The patient complained of intense pain, anxiety, and discomfort. Fluoroscopy depicted severe RA spasm (RAS) (Figure 1A and Video Series). Prolonged occlusion flow-mediated dilation and balloon-assisted techniques failed. Sheath withdrawal avulsed an RA fragment (2 cm long) protruding through the access site (Figure 1B).

Transradial access leads to anatomical and functional changes in the vessel wall due to puncture or material-associated trauma, inflammation, and loss of the endothelium’s nitric oxide vasodilatory response. Despite the superficial and palpable RA course, caution and dexterity are important assets when puncturing, wiring, inserting the sheath, or maneuvering the catheters. RA anatomic variations, tortuosity, and RAS are related to femoral access switch.

The outer diameters of sheaths and catheters need to match with the RA internal diameter, otherwise, friction or vascular stretch will occur, activating the surface endothelium and the coagulation cascade. Friction between the arterial wall and the equipment worsens endothelial function and precipitates patient discomfort, RAS, and ultimately, radial artery occlusion. An intra-arterial mixture of vasodilators (verapamil 5 mg and nitroglycerin 100-200 µg) reduces RAS and should be administered following sheath insertion, in between catheter changes, and just before sheath removal.

In our patient, repeated administration of local anesthesia with subcutaneous lidocaine and mild sedation with 1 mL of midazolam minimized nervousness, distress, and soreness perception, while serial delivery of subcutaneous and intra-arterial verapamil and nitroglycerin provoked local RA vasodilation tackling the spasm. The RA was then punctured proximally (Figure 1C). The avulsed RA fragment was excised (Figure 1D)and minimal bleeding required no further intervention. Radial pulse remained palpable, possibly because the adventitia remained intact or the avulsed RA fragment formed a minor RA branch. Histopathology was unavailable. CA was unremarkable (Video Series) and at 1-month follow-up, vascular ultrasound portrayed uncompromised blood flow (Figure 1E).

Affiliations and Disclosure

From the ¹Cardiology Department, Trikala Hospital, Trikala, Thessaly, Greece; ²School of Health Sciences, University of Thessaly, Larissa, Greece; ³Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted September 15, 2022.

Address for correspondence: Dimitrios Karelas, MD, MSc, Cardiology Department, R. Feraiou 13, 43100, Karditsa, Greece. Email: dim.f.karelas@gmail.com

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